Application for Authority to Employ Full-Time Students at Subminimum Wages in Retail or Service Establishments or Agriculture Under Regulations 29 C.F.R. Part 519 U.S. Department of Labor Employment Standards Administration Wage and Hour Division 230 South Dearborn Street, Room 514 Chicago, Illinois 60604-1757 Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. OMB No.: 1215-0032 Expires: 10-31-2011 This is an application for retail or service establishments or agricultural employers to obtain authority to employ more than six full-time students at subminimum wage rates under Section 14(b) of the Fair Labor Standards Act (FLSA). The subminimum rates paid full-time students under Section 14(b) may not be less than 85 percent of the applicable minimum wage under Section 6 of the FLSA. Employers requesting authority to employ six or fewer full-time students at subminimum wage rates throughout a single enterprise must submit Form WH-202 rather than this form. Please submit one copy of the completed form to the address shown above. Retain a completed copy for your records. A certificate may not be granted unless a properly completed application has been received and approved. 1. This is (check one): 4. Establishment covered by this application where full-time students will be employed at subminimum wages if different than block 3: Initial Application Renewal Application (complete following): Name of Establishment: Current Certicate Number: Street Address: Certificate Expiration Date: / / City: 2. Authority Requested (check one): State: Zip: Check here if mail is to be sent to above address rather than to address listed in block 3: Ten percent of the total monthly hours Greater than ten percent of the total monthly hours (you must complete Block #6 below if this is an initial application) 5. Type of establishment (check one): Grocery Store City: State: Zip: Hotel/Motel Movie/Theater Mailing Address (if different than street address): Fast Food Restaurant Clothing/Shoe Store Street Address: Full Service Restaurant Convenience Store 3. Name of Employer: General Merchandise Hospital/Nursing Home Federal Employer Identification Number (EIN): Other Retail/Service, Specify Type: Agriculture, Specify Crop/Product: A separate application is required for each establishment or farm for which authority is requested to employ fulltime students at subminimum wages. 6. This item need only be completed on initial request for more than ten percent – See 29 C.F.R. §519.6(f)-(h) A. Calendar Month January February March April May June July August September October November December B. Year C. D. Total Hours of fullhours time students of all that were paid employees subminimum wages E. F. Full-time Percentage student hours allowance as percent of requested total hours (D ÷ C) X 100% % % % % % % % % % % % % % % % % % % % % % % % % G. Check one: Check here if you used data from your own establishment. Check here if you used base year data from another establishment and provide the name and address of the establishment below: Form WH-200 Rev. June 2008 see reverse American LegalNet, Inc. www.FormsWorkflow.com 7. If this is a renewal application, please provide the following information for the establishment named in block #4: FOR USDOL USE ONLY Pending Denied Issued Withdrawn A. The total number of hours worked by all employees (including managers) during the most recent 12 months: Revoked Issue/W Pend. RO B. The total number of hours worked by full-time students during the most recent 12 months that were paid at subminimum wage rates: DO Print Cert. Effective C. The total number of full-time students who were paid subminimum wages during the most recent 12 months (if you had no full-time students paid less than the minimum wage, enter “0”) New Cert No. / Base year: / 60/61 Expiration 66/67 73/74 / / Archive Remarks: 8. Person USDOL should contact regarding this application: Name: Telephone No.: ( ) 9. REPRESENTATIONS AND WRITTEN ASSURANCES: Your signature on this application certifies that you have read the application and that to the best of your knowledge and belief the answers and information given in the application are true; that the representations set forth in support of this application to obtain full-time student authorization are true; that you are duly authorized to sign this application; and that the authorization, if issued, is subject to withdrawal or annulment in accordance with 29 C.F.R. part 528. I represent that as set forth in regulations governing the employment of full-time students (29 C.F.R. part 519) the following conditions exist in this establishment: (a) The issuance of the authority requested herein is necessary to prevent a curtailment of opportunities for employment. (b) The employment of full-time students will not create a substantial probability of reducing the full-time employment opportunities of persons other than those employed under the regulations. (c) Full-time students are available for employment at subminimum wages. (d) Abnormal labor conditions, such as a strike or lockout, do not exist at this establishment. (e) There are no serious outstanding violations of the provisions of previous full-time student authority issued to this establishment nor have there been any serious violations of other provisions of the FLSA. (f) Full-time students are employed in compliance with applicable local ordinances, State laws, and other Federal laws. (g) The issuance of this authority will not result in a reduction of a wage rate paid to a current employee, including student employees. 10. SIGNATURE OF AUTHORIZED REPRESENTATIVE: Name (Print or Type) Title Signature Date This application form must be completed to receive a certificate authorizing the employment of more than six full-time students at subminimum wage rates (which may not be less than 85% of the applicable minimum wage) in retail or service establishments and in agriculture. Please consult 29 C.F.R. part 519 for detailed information concerning the employment of full-time students at subminimum wage rates. Please submit the completed application to the Wage and Hour Division at the address listed on the front of this form. Public Burden Statement We estimate that it will take an average of 11 to 31 minutes per response to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection information, and maintaining your records. If you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor, Administrator, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C., 20210 (please do not send the completed application to this address). 2 American LegalNet, Inc. www.FormsWorkflow.com Form WH-200 Rev. June 2008